Dennis D. Kim

Peripheral Nervous System and Vascular Disorders Affecting Mobility in Older Adults

Peripheral nervous system disorders (PNSDs) and peripheral vascular disorders (PVDs) are underrecognized etiologies of impaired mobility despite the increasing prevalence among older adults. PNSDs and PVDs are clinical diagnoses and based on history and physical examination to localize and characterize the pathologies. Diagnostic tests include electromyography, serologic tests, and imaging studies for PNSDs, and vascular studies including the ankle-brachial index and ultrasonography for PVDs. Management of PNSDs requires a multidisciplinary approach including patient education, therapeutic exercises, orthotics, and pharmacologic management for neuropathic pain. Management of PVDs includes the modification of risk factors, antiplatelet agents, pharmacologic management, and exercise training.

Poster 229 Athlete with Compression of Thenar Motor Branch and Thumb Digital Branch of Median Nerve: A Case Report.

Main Outcome Measures: N/A. Results: Initial combined search results produced 2398 articles. After exclusion based on title 83 articles remained. An additional 19 articles were excluded upon review of abstracts, leaving 64 articles for full manuscript review. There were 29 studies treating movement disorders, subdivided into dystonia (n1⁄410), Parkinson’s disease (n1⁄46), progressive supranuclear palsy (n1⁄46), spinocerebellar ataxia (n1⁄42), catatonia (n1⁄43), and tardive dyskinesia (n1⁄41); 24 studies treating disorders of consciousness, from causes such as traumatic brain injury (n1⁄45), anoxic brain injury (n1⁄46), and other encephalopathies (n1⁄42); and 11 studies treating other neurologic conditions including stroke (n1⁄44) and dementia (n1⁄42). Study designs included case reports or series (n1⁄435), single subject interventional (n1⁄414), randomized controlled trials (n1⁄46), nonrandomized controlled trials (n1⁄44), and cross-over studies (n1⁄44). Only 14 studies had greater than five subjects. Sedation was observed in eight studies. Conclusions: Zolpidem has been observed to treat a large variety of neurologic disorders, most often related to movement disorders and disorders of consciousness. Much of what is known comes from case reports and small interventional trials. Additional research with larger randomized controlled trials is needed to better understand zolpidem’s efficacy in treating these conditions. Level of Evidence: Level III

Poster 51 Electrodiagnostic Findings in Anterior Spinal Cord Syndrome: A Case Report

Participants: OEF/OIF Veterans with mTBI (N1⁄457). The majority of participants were male (89.5%) with a mean age of 32.5 and two combat deployments. Interventions: Not applicable Main Outcome Measures: Clinical interviews were used to assess lifetime history of mTBI and PTSD. Questionnaires included the Moral Injury Events Scale (MIES), Spiritual Health and Life-Orientation Measure (SHALOM), and Brief Multidimensional Measure of Religiousness/ Spirituality (BMMRS). Results or Clinical Course: Participants reported high levels of perceived moral transgressions (M1⁄420.8, SD1⁄48.1) and perceived moral betrayals (M1⁄411.1, SD1⁄44.5), as well as high rates of PTSD diagnoses (86%). Discrepancies were found between ideal (M1⁄416.2) and current (M1⁄412.5) levels of spiritual health. Preliminary results suggest a preference for individuals to identify as spiritual rather than religious (M1⁄4 2.5, 3.1, respectively, SD1⁄41). Further, 33.4% of the sample identified as atheist, agnostic, or as having no religion, while 50.8% identified as Christian. Conclusion: Preliminary data reveal rates of moral injury, spiritual health, and post-traumatic stress disorder. Veterans with mTBI reported greater moral injury than has been previously reported in other military samples. Discrepancies found between ideal and current states of spiritual health highlight unsatisfactory spiritual well-being. Religious preferences (or rejection thereof) were noteworthy. These findings call attention to potential factors associated with PCS maintenance, and reinforce the need for continued exploration of moral injury and spirituality.

Poster 282 A Temporary Trial of an Anterior Shell to Evaluate Gait Abnormalities in a Patient Not Responsive to a Semi-rigid AFO: A Case Report

Disclosures: A. J. Chrisman: I Have No Relevant Financial Relationships To Disclose. Case Description: A 47-year-old African American woman with no significant past medical history presented to the Emergency Department (ED) with right buttock pain one month after slipping on her porch, landing directly on her buttocks. She had been seen in the same ED one week prior. At that time imaging revealed a resolving hematoma over the right gluteal region but no bony abnormalities of the pelvis or femur. The pain was localized, sharp, and constant but worsened with ambulation, severely limiting her mobility over the prior ten days. She denied any left sided, constitutional, bowel or bladder symptoms. Her musculoskeletal and neurological examination was normal except for tenderness over the right gluteal region and weakness in right hip abduction and extension (MRC 4/5). Setting: Tertiary care hospital. Results or Clinical Course: EMG was ordered and revealed an isolated inferior gluteal nerve neuropathy with evidence of re innervation. The patient was discharged from the ED with a prescription for physical therapy and follow up with Physical Medicine and Rehabilitation. Discussion: The inferior gluteal nerve originates from the lumbosacral plexus and passes through the greater sciatic foramen inferior to the piriformis muscle. Inferior gluteal neuropathy is a rarely reported but recognized complication of the posterior approach to hip arthroplasty. It is also subject to injury by compression and ischemia in sedentary individuals and following penetrating trauma. This case demonstrates a unique cause of an isolated inferior gluteal neuropathy from hematoma which can be missed as occurred with this patient on her first visit to the ED. Furthermore, diagnostic imaging of peripheral nerves in the hip is challenging due to the complex regional anatomy. For this reason, electro-diagnostics can be a valuable tool to localize the injury and provide prognosis as seen in this case. Conclusion: The inferior gluteal nerve’s position makes it vulnerable to injury during hip arthroplasty, prolonged compression, ischemia and penetrating trauma. This case illustrates that inferior gluteal neuropathy can also result from a hematoma and this should be could considered in the differential when examining patients.

Poster 306 Dermatomyositis and Bilateral Knee Arthralgia as a Rare Presentation: A Case Report

Disclosures: B. Cherubini, No Disclosures. Case Description: The patient was referred for bilateral knee pain; she had been complaining of generalized arthralgia for 1 year mostly in the knees, the pain is worse in the morning and when standing up from a sitting position. It does not improve with medication (ibuprofen, diclophenac). Physical examination revealed bilateral Madelung’s deformities at the wrist and erythematous patches scattered over face, chest, thigh, and hands. Gait was normal but could not tolerate toe and heel walking secondary to pain. On manual muscle testing, there was proximal muscle weakness of the hip flexors, hip extensors, deltoid bilaterally and neck flexors. Laboratory testing showed significantly increased creatine kinase (5618 U/L) and serum myoglobulin (1213 ng/mL); other rheumatologic and immunologic blood tests were normal. Nerve conduction studies showed normal sensory conduction and motor conduction with low amplitudes of the CMAPs with normal conduction velocities; needle electromyography showed fibrillations and abnormal spontaneous activity in proximal muscles including the ilio-psoas muscle. Program Description: 43-year-old woman with bilateral knee arthralgia. Setting: Adult rehabilitation clinic. Results or Clinical Course: After the clinical examination of the patient in our service, myopathy was suspected. Laboratory test and NCS/EMG findings were suggestive of inflammatory myopathy. Patient will initiate physical therapy and will also be seen by neurology. Discussion: This is a case of a patient with dermatomyositis and chief complaint of knee pain as initial presentation. Arthralgias, arthritis, or both, may be present in up to a quarter of patients with inflammatory myopathy, commonly as a complication and accompanied by morning stiffness. Conclusions: Bilateral knee arthralgia produces an unusual and diagnostically challenging picture in this patient, but dermatomyositis must be suspected in patients with clinically compatible cutaneous findings to start early treatment and avoid complications.

Poster 219 Intersection Syndrome Presenting With Dorsal Thumb Pain: A Case Report

prioception, and strengthening, and returned to light running on an AlterG treadmill. He was bearing full weight during running activities 8 weeks after the fracture diagnosis but missed the remainder of the track season. Discussion: Ankle inversion injuries are relatively common occurrences in collegiate sports. However, low-impact tibial fractures after acute ankle sprains are primarily documented in the adolescent population and are rarely reported in skeletally mature collegiate athletes without significant trauma. Conclusions: Recurrent ankle pain despite adequate conservative treatment may indicate additional osteochondral or ligamentous pathology and requires further evaluation.

Poster 173: Interdigital Neuritis Mimicking Lumbosacral Radiculopathy Among Patients Referred for Electrodiagnostic Study: Case Series

Disclosures: J. R. Babington, None. Patients or Programs: A 43-year-old woman undergoing a thoracic transforaminal epidural steroid (TFESI) injection for chronic left T6 radicular pain. Program Description: The patient presented with chronic radicular pain from a left T5-6 paracentral disk protrusion recalcitrant to conservative care. She underwent a left T6 TFESI injection. Injectate consisted of 1.5 mL triamcinolone 40 mg/mL and 1.5 mL 2% MPF free lidocaine mixture that was injected under fluoroscopic visualization without the use of digital subtraction angiography. Intraoperatively, no vascular infiltration was observed on epidurography. Patient developed sensory and motor impairment 20 minutes after injection. MRI performed 7 days after injection revealed a T2 hyperintense signal at T5 cranial from injection site. Setting: Ambulatory surgery center. Results: The patient sustained a T5 ASIA D spinal cord injury after thoracic TFESI. Vascular uptake of contrast was noted upon post hoc review of the intraoperative fluoroscopic images. As previously observed in the cervical and lumbar spine, this finding suggests that intraoperative vascular infiltration may pose a risk for spinal cord injury. Discussion: This is the first case report of spinal cord injury after TFESI in the thoracic spine. The data supporting the use of this procedure is currently extrapolated from studies in the lumbar and cervical regions or based on anecdotal evidence. Complex anatomy creates a high level of risk in performing this procedure. Conclusions: Although digital subtraction angiography and non-particulate steroids may aid in performing this procedure with the highest margin of safety, a highly experienced and well-trained operator is essential. It is imperative that further randomized controlled trials be performed to demonstrate efficacy.

Poster 133: Extension Contracture After Total Knee Joint Arthroplasty Caused by Adhesive Neuritis and Successful Treatment with Nerve Block Injection: A Case Report

Disclosures: M. R. Kuthuru, None. Patients or Programs: A 72-year-old man presented with severe lumbar spinal stenosis. Program Description: Patient had marked leg weakness with ambulation problems. Medial branch blocks were performed in 06/06 with minimal benefit. Manipulation under anesthesia of the lumbosacral spine and pelvis was performed with some benefit in 08/06. A further set of medial branch blocks did not show any benefit. An electrodiagnostic study in 07/07 was consistent with spinal stenosis. Caudal epiduroplasties were performed in 10/07, 11/07 and 03/08. The caudal epidural space was accessed. 30-50 mL of a mixture of lidocaine, bupivacaine and normal saline was infused. An epidurogram was obtained using 10 mL of radiopaque dye. Setting: Office-based surgical center. Results: Patient reported excellent results after epiduroplasties with marked reduction of pain and improvement of ambulation. He required medial branch blocks for severe axial pain after a subsequent fall. Further epiduroplasties were planned. Discussion: Spinal stenosis commonly affects older adults and causes disability. Axial pain, weakness and mobility deficits are seen. It is highly resistant to conservative treatment. Multiple comorbidities limit surgical options. We present a new technique to remodel the epidural space. These techniques are performed in the lumbar spine via a caudal access route, using either cannulation or an epidural catheter. These techniques can also be performed at the neural foramen with cannulation, epidural catheters or pulsatile jets. These procedures can also be performed in the cervical, thoracic and lumbar spine. Further studies are recommended to evaluate long-term benefits so this may be widely used in this population subset. Conclusions: Epiduroplasty is a safe, repeatable procedure to remodel the epidural space to decrease pain and disability in the geriatric population.

Foot and ankle disorders associated with functional impairment in the elderly

Maintaining mobility is critical for the elderly because decreased mobility compromises their reduced neuromuscular and cardiopulmonary reserve capacities. Lack of weight-bearing activities contributes to the development of progressive osteopenia and osteoporosis which may lead to serious medical problems. Maintenance of independent ambulation allows the elderly to participate in social activities, reducing depression and promoting general wellbeing. Fear of falling is one of the main concerns of the institutionalized elderly as well as their caregivers, and discourages active ambulation [1]. Although impaired mobility due solely to foot problems seems relatively rare in the elderly, mobility requires healthy feet. Practicing physicians frequently overlook chronic foot disorders in the elderly because they mostly result from a lifetime of use and are seldom life-threatening. Physicians in general may not be concerned about foot complaints and may never examine their patient’s feet or shoes. On the other hand, some specialists like to treat foot problems surgically as a quick and convenient way to solve foot problems of the elderly. This article will discuss foot and ankle disorders associated with musculoskeletal dysfunction, and systemic diseases that affect the lower extremities. Conditions well described in many other textbooks, such as corns, calluses, hammer and claw toes, bunions, and